Impact of ACA on Gender-Affirming Care: Urology Study Insights - Akanksha Mehta & Eric Walton
July 12, 2024
Ruchika Talwar interviews Eric Walton and Akanksha Metha about their study on the impact of legislation on access to gender-affirming care, published in the Gold Journal. The research examines the effects of the Affordable Care Act on insurance coverage for transgender and gender-diverse adults using the MarketScan Commercial Claims database from 2009 to 2022. The study reveals a significant increase in both the incidence of transgender individuals in the database and insurance claims for gender-affirming surgeries, with a notable inflection point in 2017. The researchers discuss the importance of policy changes in expanding access to care, the challenges in cost-sharing, and the need for urologists to be prepared for an increasing demand for gender-affirming care. They emphasize the positive impact of sustained policy efforts on patient care and the importance of advocating for inclusive healthcare policies.
Biographies:
Akanksha Mehta, MD, MS, Assistant Professor of Urology, Emory University School of Medicine, Director of Male Reproductive Health, Emory Urology, Atlanta, GA
Eric Walton, MD, University of North Carolina at Chapel Hill, Chapel Hill, NC
Ruchika Talwar, MD, Assistant Professor of Urology, Urologic Oncologist, and Associate Medical Director in Population Health, Vanderbilt University Medical Center, Nashville, TN
Biographies:
Akanksha Mehta, MD, MS, Assistant Professor of Urology, Emory University School of Medicine, Director of Male Reproductive Health, Emory Urology, Atlanta, GA
Eric Walton, MD, University of North Carolina at Chapel Hill, Chapel Hill, NC
Ruchika Talwar, MD, Assistant Professor of Urology, Urologic Oncologist, and Associate Medical Director in Population Health, Vanderbilt University Medical Center, Nashville, TN
Read the Full Video Transcript
Ruchika Talwar: Hi, everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar, and I'm a urologic oncologist at Vanderbilt in Nashville, Tennessee. I'm really excited today to be joined by Dr. Metha, who's at Emory, and Dr. Walton, who's a reconstructive urology fellow at UNC Chapel Hill. They will be discussing important work that they recently published, looking at gender-affirming care in urology. Thank you both for joining us today.
Akanksha Metha: Thanks for having us.
Eric Walton: Yeah, thank you so much. This is exciting. Again, my name's Eric Walton. I just graduated from Emory, and we'll be talking about our paper that we just published in the Gold Journal about the impact of legislation on access to gender-affirming care.
Our project focused on the Affordable Care Act that was passed in March of 2010, and ultimately after a series of legislative issues took effect in January of 2017 with regards to gender identity and gender transition-related care. And we wanted to evaluate the impact that it had on the availability and coverage of gender-affirming care with regards to commercial insurance coverage. Because the Affordable Care Act, while it is a public policy, applies to any program funded or administered by the government, including marketplaces.
Our study design used the MarketScan Commercial Claims database, and we looked at transgender and gender diverse adults in this database from the time period of January 1, 2009, through June 30, 2022. Our primary outcomes were looking at the incidence of transgender and gender diverse persons in this database, the incidence of insurance claims for gender-affirming surgery, and then secondary outcomes with a temporal relationship between these claims and anti-discrimination legislation, notably the ACA, as well as a cost analysis.
We set up our methods focused on a study cohort design that was developed in this paper, Jasuja et al. Most people, when they're researching gender-affirming care, they stick to gender identity disorder ICD codes. This protocol that they developed that we adopted includes ICD codes for unspecified endocrine disorders, as well as CPT codes for gender-affirming surgery, and codes for sex discordant hormone therapy. And we put this all together to generate our study cohort so it would be broader than the typical studies. We did exclude anyone who had ICD codes from malignancies or who were pediatric patients. Ultimately, 87% of our cohort was from the gender identity ICD codes, but we did add an additional 9,000 plus individuals with the other components of our algorithm. And ultimately we had 70,733 gender diverse adults, of whom 44% were transfeminine and 55% were transmasculine based on these codes.
Of this group, 51% had claims for gender-affirming care in the database, meaning that it had been submitted and it was accepted, and there were more hormone therapy-related claims than surgical claims. If you look at the time period that we studied, on the left is the incidence of transgender and gender diverse individuals in the database, and it clearly increased over the time period. It actually increased by a factor of 10 up to 0.066%. And on the right, we have gender-affirming surgical claims, the top line being any, and then the lower lines being broken down into genital surgeries, chest surgeries, and facial surgeries. It clearly increased over this study period by a sixfold factor. And then looking at the specific surgeries that there were claims for, the most common at the beginning of the study period was hysterectomy, and the most common at the end was mastectomy, and then the least was mammoplasty, and the most common... Or sorry, the least common at the end was orchiectomy.
Jumping into the time series analysis, which is a special type of statistical analysis to see if there's a change in the slope before and after a particular time point, we were able to show that before 2017, there was a slower rate of increase in gender-affirming surgical claims compared with afterwards. This image here is representative for all gender-affirming surgeries, but we did this analysis for each subtype and the trend was the same. So this shows that centered around 2017 as an inflection point, there was an increase in the year-to-year increase of gender-affirming surgical claims.
And briefly, for a cost analysis, we saw that hormone therapy had a median patient contribution of $92, which is about 34%. And for surgical claims, the contribution was around $1,000, which represents approximately 8.5%. And the patient contribution did decrease throughout the study period.
Ruchika Talwar: Thanks so much, Dr. Walton. Really, really interesting analysis. Very relevant, obviously, and you bring up some important points I want to dig into a bit more. Specifically looking at that inflection time point you noted in your graph, what do you think was significant about 2017?
Eric Walton: I started to point at this at the beginning of the presentation, but 2017 was when the Affordable Care Act, after it had gone through legislative challenges, affected the majority of insurance companies who are using the marketplace.
If you look at the data, you can see that before 2017 things are changing, and that's because the ACA took effect technically in 2010 when it was passed. But it really started to affect insurance companies at that 2017 time point based on what I was able to find in the legal literature.
Ruchika Talwar: Okay. So essentially access was expanded in 2017 from a practical standpoint. Dr. Mehta, any thoughts on that?
Akanksha Metha: Yeah, I think these big policy changes, and this was certainly a big policy change for this population, always take a few years to gain traction, and for the insurance companies, particularly the private insurance providers to catch up to the policy changes. Also, it takes time, I think, for patients to adapt to those changes and really be willing to come forward.
Undergoing any kind of gender-affirming care, whether it's medical or surgical, is a major step for this patient population, as you understand. And it does require time to, I think, find the right physician, the healthcare setting, and the healthcare system where these patients feel comfortable seeking care. We actually have a follow-up paper coming out in hopefully the next few months looking at the geographic spread of where care is offered and received, which I think will delve into some of those questions a little bit more.
Ruchika Talwar: Yeah, absolutely. I mean, certainly these patients will require complex reconstructive procedures, often more than one. So you want care to be centralized at a Center of Excellence. And then as we all know, especially in today's day and age, there are state-level variations in whether care is available or if access is restricted or whatnot. So I applaud you both for doing these kinds of claims analysis because I think it's important to understand where we were, where we are going, and how variations in legislative priorities throughout the country can affect this patient population.
You also did look into cost sharing, which I thought was interesting. For the surgical patients, it looked like the cost sharing was somewhere around $1,000. That was actually less than I was expecting. So I was curious if you both could share your thoughts on that.
Akanksha Metha: Yeah, it was less than we were expecting as well. I honestly expected that number to be quite a bit higher, but pleasantly surprised to see that.
Eric Walton: Yeah, I agree. I expected it to be much higher. I think the important thing to remember is that the people who are included in our study are people who had their claims accepted. So if you didn't have your claims accepted, if you didn't submit a claim, then you're paying 100%.
Ruchika Talwar: Yeah, absolutely.
Akanksha Metha: I think that's a really important point actually that Eric just made because if you look at the number of transgender individuals that were identified in the cohort, the smaller subset of patients for whom claims were submitted for either medical or surgical therapy, that was actually the minority of the patients. So either the patients are just not seeking care, which I doubt, or they just don't... Those claims are not getting covered.
Ruchika Talwar: Yeah, I think that makes a lot of sense. And perhaps for the subset of patients who can't afford to have high copays or perhaps are in a situation where their procedures may not be covered, obtaining gender-affirming surgery could certainly be cost prohibitive for them.
But it was reassuring to see, at least for those who were able to have their procedures covered, overall cost sharing was low. And I was also reassured by the fact that for patients on hormone therapy, cost sharing was under $100.
Akanksha Metha: Yeah.
Eric Walton: Absolutely. And I think it's important to note from the hormone perspective that there are good options through GoodRx and other things that require patients to not submit anything for insurance claims because they're actually less than what they're paying through insurance.
Ruchika Talwar: Yeah, absolutely, absolutely. Well, as we wrap up here, I'll ask each of you, Dr. Walton, perhaps you can go first. What are your biggest takeaways from this study for the urologic community?
Eric Walton: My biggest takeaways for the urologic community are that gender-affirming care is increasingly important and increasingly covered. So it's something that we need to be prepared for and have... Even if you're not a gender-affirming surgeon, you need to be prepared to see patients who need this care because they're going to come in the door.
And that policy initiatives matter. And so if there's an opportunity to advocate for a policy that you think could make a change for your patients, then you should do that.
Ruchika Talwar: Absolutely. Dr. Metha?
Akanksha Metha: Yeah, I would echo that. And I think my takeaway is the second point that Dr. Walton made, which is that policy changes can be so impactful. And particularly in our current climate where there is so much debate on where we focus our efforts, I think it's important to remember that, as physicians, we have promised to take care of all our patients, so we should really not be leaving any patient group behind. And a small and sustained effort, as this was, to create this change back in 2014 has clearly positively impacted so many of our patients and will hopefully continue to be the case.
Ruchika Talwar: Absolutely. And just a reminder to our UroToday community. As urologists, we are most certainly involved with our trans patients' care, so this certainly is a call to action to ensure that we can preserve access and optimize outcomes in this community.
Thank you so much for joining us today here at UroToday. We really appreciate your time and I learned a lot from this conversation. I'm glad we were able to share it.
Akanksha Metha: Thank you so much.
Eric Walton: Thank you so much. It was a pleasure.
Ruchika Talwar: Great. And to our audience, thanks for joining. We'll see you next time.
Ruchika Talwar: Hi, everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar, and I'm a urologic oncologist at Vanderbilt in Nashville, Tennessee. I'm really excited today to be joined by Dr. Metha, who's at Emory, and Dr. Walton, who's a reconstructive urology fellow at UNC Chapel Hill. They will be discussing important work that they recently published, looking at gender-affirming care in urology. Thank you both for joining us today.
Akanksha Metha: Thanks for having us.
Eric Walton: Yeah, thank you so much. This is exciting. Again, my name's Eric Walton. I just graduated from Emory, and we'll be talking about our paper that we just published in the Gold Journal about the impact of legislation on access to gender-affirming care.
Our project focused on the Affordable Care Act that was passed in March of 2010, and ultimately after a series of legislative issues took effect in January of 2017 with regards to gender identity and gender transition-related care. And we wanted to evaluate the impact that it had on the availability and coverage of gender-affirming care with regards to commercial insurance coverage. Because the Affordable Care Act, while it is a public policy, applies to any program funded or administered by the government, including marketplaces.
Our study design used the MarketScan Commercial Claims database, and we looked at transgender and gender diverse adults in this database from the time period of January 1, 2009, through June 30, 2022. Our primary outcomes were looking at the incidence of transgender and gender diverse persons in this database, the incidence of insurance claims for gender-affirming surgery, and then secondary outcomes with a temporal relationship between these claims and anti-discrimination legislation, notably the ACA, as well as a cost analysis.
We set up our methods focused on a study cohort design that was developed in this paper, Jasuja et al. Most people, when they're researching gender-affirming care, they stick to gender identity disorder ICD codes. This protocol that they developed that we adopted includes ICD codes for unspecified endocrine disorders, as well as CPT codes for gender-affirming surgery, and codes for sex discordant hormone therapy. And we put this all together to generate our study cohort so it would be broader than the typical studies. We did exclude anyone who had ICD codes from malignancies or who were pediatric patients. Ultimately, 87% of our cohort was from the gender identity ICD codes, but we did add an additional 9,000 plus individuals with the other components of our algorithm. And ultimately we had 70,733 gender diverse adults, of whom 44% were transfeminine and 55% were transmasculine based on these codes.
Of this group, 51% had claims for gender-affirming care in the database, meaning that it had been submitted and it was accepted, and there were more hormone therapy-related claims than surgical claims. If you look at the time period that we studied, on the left is the incidence of transgender and gender diverse individuals in the database, and it clearly increased over the time period. It actually increased by a factor of 10 up to 0.066%. And on the right, we have gender-affirming surgical claims, the top line being any, and then the lower lines being broken down into genital surgeries, chest surgeries, and facial surgeries. It clearly increased over this study period by a sixfold factor. And then looking at the specific surgeries that there were claims for, the most common at the beginning of the study period was hysterectomy, and the most common at the end was mastectomy, and then the least was mammoplasty, and the most common... Or sorry, the least common at the end was orchiectomy.
Jumping into the time series analysis, which is a special type of statistical analysis to see if there's a change in the slope before and after a particular time point, we were able to show that before 2017, there was a slower rate of increase in gender-affirming surgical claims compared with afterwards. This image here is representative for all gender-affirming surgeries, but we did this analysis for each subtype and the trend was the same. So this shows that centered around 2017 as an inflection point, there was an increase in the year-to-year increase of gender-affirming surgical claims.
And briefly, for a cost analysis, we saw that hormone therapy had a median patient contribution of $92, which is about 34%. And for surgical claims, the contribution was around $1,000, which represents approximately 8.5%. And the patient contribution did decrease throughout the study period.
Ruchika Talwar: Thanks so much, Dr. Walton. Really, really interesting analysis. Very relevant, obviously, and you bring up some important points I want to dig into a bit more. Specifically looking at that inflection time point you noted in your graph, what do you think was significant about 2017?
Eric Walton: I started to point at this at the beginning of the presentation, but 2017 was when the Affordable Care Act, after it had gone through legislative challenges, affected the majority of insurance companies who are using the marketplace.
If you look at the data, you can see that before 2017 things are changing, and that's because the ACA took effect technically in 2010 when it was passed. But it really started to affect insurance companies at that 2017 time point based on what I was able to find in the legal literature.
Ruchika Talwar: Okay. So essentially access was expanded in 2017 from a practical standpoint. Dr. Mehta, any thoughts on that?
Akanksha Metha: Yeah, I think these big policy changes, and this was certainly a big policy change for this population, always take a few years to gain traction, and for the insurance companies, particularly the private insurance providers to catch up to the policy changes. Also, it takes time, I think, for patients to adapt to those changes and really be willing to come forward.
Undergoing any kind of gender-affirming care, whether it's medical or surgical, is a major step for this patient population, as you understand. And it does require time to, I think, find the right physician, the healthcare setting, and the healthcare system where these patients feel comfortable seeking care. We actually have a follow-up paper coming out in hopefully the next few months looking at the geographic spread of where care is offered and received, which I think will delve into some of those questions a little bit more.
Ruchika Talwar: Yeah, absolutely. I mean, certainly these patients will require complex reconstructive procedures, often more than one. So you want care to be centralized at a Center of Excellence. And then as we all know, especially in today's day and age, there are state-level variations in whether care is available or if access is restricted or whatnot. So I applaud you both for doing these kinds of claims analysis because I think it's important to understand where we were, where we are going, and how variations in legislative priorities throughout the country can affect this patient population.
You also did look into cost sharing, which I thought was interesting. For the surgical patients, it looked like the cost sharing was somewhere around $1,000. That was actually less than I was expecting. So I was curious if you both could share your thoughts on that.
Akanksha Metha: Yeah, it was less than we were expecting as well. I honestly expected that number to be quite a bit higher, but pleasantly surprised to see that.
Eric Walton: Yeah, I agree. I expected it to be much higher. I think the important thing to remember is that the people who are included in our study are people who had their claims accepted. So if you didn't have your claims accepted, if you didn't submit a claim, then you're paying 100%.
Ruchika Talwar: Yeah, absolutely.
Akanksha Metha: I think that's a really important point actually that Eric just made because if you look at the number of transgender individuals that were identified in the cohort, the smaller subset of patients for whom claims were submitted for either medical or surgical therapy, that was actually the minority of the patients. So either the patients are just not seeking care, which I doubt, or they just don't... Those claims are not getting covered.
Ruchika Talwar: Yeah, I think that makes a lot of sense. And perhaps for the subset of patients who can't afford to have high copays or perhaps are in a situation where their procedures may not be covered, obtaining gender-affirming surgery could certainly be cost prohibitive for them.
But it was reassuring to see, at least for those who were able to have their procedures covered, overall cost sharing was low. And I was also reassured by the fact that for patients on hormone therapy, cost sharing was under $100.
Akanksha Metha: Yeah.
Eric Walton: Absolutely. And I think it's important to note from the hormone perspective that there are good options through GoodRx and other things that require patients to not submit anything for insurance claims because they're actually less than what they're paying through insurance.
Ruchika Talwar: Yeah, absolutely, absolutely. Well, as we wrap up here, I'll ask each of you, Dr. Walton, perhaps you can go first. What are your biggest takeaways from this study for the urologic community?
Eric Walton: My biggest takeaways for the urologic community are that gender-affirming care is increasingly important and increasingly covered. So it's something that we need to be prepared for and have... Even if you're not a gender-affirming surgeon, you need to be prepared to see patients who need this care because they're going to come in the door.
And that policy initiatives matter. And so if there's an opportunity to advocate for a policy that you think could make a change for your patients, then you should do that.
Ruchika Talwar: Absolutely. Dr. Metha?
Akanksha Metha: Yeah, I would echo that. And I think my takeaway is the second point that Dr. Walton made, which is that policy changes can be so impactful. And particularly in our current climate where there is so much debate on where we focus our efforts, I think it's important to remember that, as physicians, we have promised to take care of all our patients, so we should really not be leaving any patient group behind. And a small and sustained effort, as this was, to create this change back in 2014 has clearly positively impacted so many of our patients and will hopefully continue to be the case.
Ruchika Talwar: Absolutely. And just a reminder to our UroToday community. As urologists, we are most certainly involved with our trans patients' care, so this certainly is a call to action to ensure that we can preserve access and optimize outcomes in this community.
Thank you so much for joining us today here at UroToday. We really appreciate your time and I learned a lot from this conversation. I'm glad we were able to share it.
Akanksha Metha: Thank you so much.
Eric Walton: Thank you so much. It was a pleasure.
Ruchika Talwar: Great. And to our audience, thanks for joining. We'll see you next time.